Published Aug 7, 2009
arelle68
270 Posts
I discovered a pretty serious medication error last week, (Signed, but not given. Involving blood pressure.) and had to file an incident report. I called the resident's family per protocol. The resident's daughter told me something like, "Well, I'll take care of it. I can guarantee you this won't happen again!" Apparently she did, because I got to work today, and found out that the nurse had been fired. It's a tough economy, and I hate to see anyone lose their job right now. I know I had to do what I did, but I feel bad for this nurse. Anyone can forget to do something sometimes. How am I supposed to feel about this?
AllSmiles225
213 Posts
Plain and simple we all know that medication errors must be reported. I personally will try to confront the nurse if it was a matter of signing something or not before I start filling out any incident reports because I know that I would want that to be done for me. We all know that sometimes we drop our pen because someones emergency bell goes on and we get back we forget to sign. There have been times when I've seen the Coumadin sheet unsigned and called the nurse at home and asked did you give such & such their coumadin because it isn't signed. 99% ofthe time they tell me they forgot to sign it and when they come in the next day they will sign it. I know it is not the way that things are supposed to go but quite frankly I think it is professional courtesy before I start filling out any paperwork.
In the case that you are describing though if a nurse is signing for medications that were never given that does need to be reported because if it is happening to one patient it may be happening to others. I don't know the circumstances under which the nurse didn't give the medication (forgetting or just being lazy) but regardless it does need to be noted. At my facility you get written up for medication errors (minor) not just fired so there must be something that I am missing.
Overall you have to remember that you have to be the advocate for your patients and if you know that something is going on that could be potentially harmful for your patient you are LEGALLY OBLIGATED to report it. I know it is hard not to feel bad about the nurse being fired but remember she wasn't fired because of you, she was fired because of her actions and her failure to adequately perform her duties. Keep your head up.
That's all I can post based on the story that you gave..
But if you don't mind me asking how did you come about finding that it was signed but not given, just out of curiousity?
JBudd, MSN
3,836 Posts
Sad for her.
Honorable for doing the right thing.
Embarressed that it happened at all in your facility.
It's not likely she got fired over just the one incident, generally there's been a pattern before someone gets fired.
But, falsifying records is pretty serious, what if something really bad had happened because of it?
Hugs to you....
lucyblue67
2 Posts
I was wondering the same thing? How did you find out?
NurseKitten, MSN, RN
364 Posts
I agree with JBudd. If it's your facility's protocol that the family is notified, and you were within your "position" to do so, then I'm sorry she lost her job, but that's what happens when you screw up, then lie to cover it up.
Plain and simple we all know that medication errors must be reported. I personally will try to confront the nurse if it was a matter of signing something or not before I start filling out any incident reports because I know that I would want that to be done for me. We all know that sometimes we drop our pen because someones emergency bell goes on and we get back we forget to sign. There have been times when I've seen the Coumadin sheet unsigned and called the nurse at home and asked did you give such & such their coumadin because it isn't signed. 99% ofthe time they tell me they forgot to sign it and when they come in the next day they will sign it. I know it is not the way that things are supposed to go but quite frankly I think it is professional courtesy before I start filling out any paperwork. In the case that you are describing though if a nurse is signing for medications that were never given that does need to be reported because if it is happening to one patient it may be happening to others. I don't know the circumstances under which the nurse didn't give the medication (forgetting or just being lazy) but regardless it does need to be noted. At my facility you get written up for medication errors (minor) not just fired so there must be something that I am missing.Overall you have to remember that you have to be the advocate for your patients and if you know that something is going on that could be potentially harmful for your patient you are LEGALLY OBLIGATED to report it. I know it is hard not to feel bad about the nurse being fired but remember she wasn't fired because of you, she was fired because of her actions and her failure to adequately perform her duties. Keep your head up.That's all I can post based on the story that you gave..But if you don't mind me asking how did you come about finding that it was signed but not given, just out of curiousity?
By the date on the Catapres patch. It hadn't been changed on the day this nurse signed for it, and the resident's BP went up.
Well yes I guess that sort of gives it away. You had to report it. You did the right thing.
wacberry
52 Posts
I try to fix the things that can be fixed. Call the other nurse and let her know. But some things can not be fixed. Like controled drugs that are not signed out. There is an accepted error rate on medications. I can't remember, I think it might be 5%, at least in Texas. I doubt the nurse was fired over just that one incident. Just don't ever start a pi$$ing match with another nurse by finding and reporting things. It will come back to bite you on the butt.
fissileflower
22 Posts
personally i would have called the nurse before taking the situation any further, i know we are nurses; which means we don't make mistakes but lets be realistic we are only human.
rn/writer, RN
9 Articles; 4,168 Posts
Giving the med and forgetting to sign for it is an understandable error, one we have probably all made at one time or another. Signing for the med and not giving it is not a lapse; it's a bad choice that can be considered falsifying records.
As others have said, it is highly unlikely that the other nurse was let go because of this one error. You don't know what's in her file or what other complaints there may have been against her. You protected your patient as you should have. You can feel bad for the other nurse, but you don't have to feel responsible. She is the one who created the problem.
Please, move on from this, and continue to be an advocate for the residents. They need you.
Katnip, RN
2,904 Posts
She didn't ge fired because of you. She got fired for a serious med error and falsifying records.
rachelgeorgina
412 Posts
Forgive me, but technically, I see no difference. The consequence of giving the medication and not signing for it and signing for it but not giving it are equally serious.